How Much Proof Do We Need to Eat Healthier?

Randomized placebo-controlled trials are considered the gold standard of scientific evidence. In such studies, half of the subjects may get the active treatment, and the other half unknowingly get a sugar pill instead. This works great for evaluating new drugs, but a concern is that evidence-based medicine has made a leap from considering randomized controlled trials to be a high standard to considering them to be the only standard. As my Evidence-Based Nutrition video argues, this may not be prudent in all circumstances. Consider a review of dietary interventions for multiple sclerosis produced by the esteemed Cochrane Collaboration. In that review, they basically concluded there’s not much diet can do. But what about the success of Dr. Swank in treating MS with a low saturated fat diet, the most effective treatment ever reported, published in some of the world’s most prestigious journals? Of course, they knew about Swank’s work, but his study design didn’t fit the inclusion criteria considered for their review, because it was not a controlled trial.

Demanding randomized trials makes sense for drugs, since drugs are expensive and risky, and their adverse side effects kill more than a hundred thousand Americans every year. But a healthy diet has no downsides—only good side-effects. So, we shouldn’t have to wait on randomized controlled trials to start potentially saving people’s lives.

Consider smoking. “[I]t took more than 7,000 studies and the death of countless habitual smokers before a consensus was reached in the medical community regarding the causal link between smoking and lung cancer.” You’d think that after the first 6,000 studies they could have given people a heads up or something? Even then, they didn’t have a single randomized controlled trial. “One has to wonder, how many people are currently suffering needlessly while they wait for a [randomized controlled trial] to confirm the results found” by other kinds of strong studies?

A famous statistician, R.A. Fisher, railed against what he called “propaganda” created to convince the public that cigarette smoking was dangerous. No definitive fact of the matter could be established, he argued, since evidence could not be produced by randomized controlled trials. If we could conduct an experiment involving, say, a thousand kids banned from smoking and another thousand who were forced to smoke at least a pack and a half a day, there would be no difficulty. But, of course, this we cannot do. Maybe, Fisher pointed out, instead of smoking causing lung cancer, lung cancer causes smoking! In its early stages, lung cancer may cause inflammation. So, anyone suffering from chronic inflammation is going to want to smoke a cigarette to make themselves feel better, and it’s that “kind of comfort that might be a real solace to anyone in the fifteen years of approaching lung cancer. And to take the poor chap’s cigarettes away from him would be rather like taking away his white stick from a blind man. It would make an already unhappy person a little more unhappy than he need be.”

Fisher made invaluable contributions to the field of statistics, but his analysis of lung cancer and smoking was “flawed by an unwillingness to examine the entire body of data available.” His smokescreen may have been because he was a paid consultant to the tobacco industry, but also because he was himself a smoker. “Part of his resistance to seeing the association may have been rooted in his own fondness for smoking,” which makes me wonder about some of the foods many modern-day nutrition researchers may be fond of as well.

A famous paper in the British Medical Journal titled, “Parachute use to prevent death and major trauma related to gravitational challenge: a systematic review of randomised controlled trials,” lampooned this insistence on randomized controlled trials as the only legitimate evidence. Not surprisingly, they didn’t find any such trials relevant to the role of parachutes in the prevention of death and trauma. Sure, parachutes appear to reduce the risk of injury after “gravitational challenge.” We can observe that people who fall out of planes without them do tend to die a bit more than those with parachutes, but their effectiveness has not been proven with randomized controlled trials. “Advocates of evidence based medicine have criticized the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organized and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.” In other words, “[i]ndividuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump.”

There are scores of randomized, controlled studies showing the extraordinary power of plant-based diets to prevent, treat, and even reverse disease. The one that did it for me 28 years ago is Dr. Ornish’s landmark Lifestyle Heart Trial, which is why I started my 2014 annual talk with it. Check out From Table to Able: Combating Disabling Diseases with Food.

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.

31 responses to “How Much Proof Do We Need to Eat Healthier?”

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There are large although admittedly retrospective studies that address all-cause mortality (ACM) in relation to vegetarianism. For individuals without a specific disease profile, ACM is arguably the most cogent criterion for obvious reasons.
Probably the largest study involves a quarter of a million Australians, and the conclusion was “no evidence that following a vegetarian diet, semi-vegetarian diet or a pesco-vegetarian diet has an independent protective effect on all-cause mortality” (https://pdfs.semanticscholar.org/9b08/642465afab42b351ee9ff5b22a0a87ed9520.pdf). We could certainly argue the validity of the methodology ad infinitum, but NTL this is one of the seminal studies if not the largest in the field. To ignore or omit it is simply inappropriate.
While the study did not stratify vegetarians into vegans and non-vegans, we can surmise from the results, by reductio ad absurdum, that the ACM of vegans is not radically different from non-vegetarians. Estimates of % of vegans among vegetarians range from > 25% to as low as 15%. Were there a significant difference between the ACM of vegans compared to non-vegan vegetarians, we would expect it to result in at least some difference between the ACM of vegetarians vs non-vegetarians, which it did not.
There may well be vegan diets that extend life (reduce ACM) to some extent, that remains to be proven. Possibly the best indication we have currently on living longer is Beutner’s work on the blue zones, which suggests a balanced diet and healthy lifestyle (exercise, low stress, social interaction, etc.) extend life. People in the blue zones are not all vegans, most consume varying but modest amounts of dairy, eggs and meat. Perhaps if the same populations had been strict vegan they would live even longer, but that’s conjecture at this juncture.
One factor that might be involved in the blue zones is compliance. Their diets and lifestyles were part and parcel of the culture of the zones. Beutner has had some success convincing relatively small populations to adopt the habits of the blue zones, with encouraging results. To what extent that’s possible in the broader population remains an open question.

Vegetarians eat dairy, eggs and processed foods.
Vegans eat processed foods.
I wouldn’t expect a study of acm involving vegetarians, a portion of which who were vegans, doesn’t speak to what can be expected in the case of whole food plant based [wfpb] nutrition.
The information that I’ve seen being disseminated on benefits of wfpb nutrition doesn’t focus just on life expectancy but also on quality of health, i.e. avoiding chronic illness and having optimal performing mind and body, for however long you do live.

Yes, and I would add in things like vegans might not be eating organic and might be having things like baked goods with aluminum and things with mercury and may not be supplementing with B-12 or Omega 3.

WFPB is the diet, which needs to be put to the test for mortality.

Could happen, now that more and more people are developing this lifestyle.

Also, I haven’t examined the Australia study, but I have examined some of the other mortality studies and they didn’t separate the pesco-vegetarian from vegetarian or vegetarian from vegan in a way to differentiate and having the pesco in the vegetarian category made it not vegetarian at all.

There is a huge difference between a vegetarian or vegan diet, and a HEALTHY vegan/vegetarian diet. This is what never seems to be addressed. If you lump those vegetarians who live on the processed vegetarian (or vegan) offerings for convenience and ease, that are full of salt, sugar, fat, oil, and other evils, it is no different that eating a SAD diet. IMO, if those are lumped into those studied, of course there will not be a major difference in all cause mortality.

He advocates a whole food plant based diet So do many other experts. Note that this is a diet based on plants not necessarily a diet comprised exclusively of plants, ie

‘A whole-food, plant-based diet is centered on whole, unrefined, or minimally refined plants. It’s a diet based on fruits, vegetables, tubers, whole grains, and legumes; and it excludes or minimizes meat (including chicken and fish), dairy products, and eggs, as well as highly refined foods like bleached flour, refined sugar, and oil.’https://www.forksoverknives.com/whole-food-plant-based-diet/#gs.Dc2GXKA

Greger and the other WFPB diet advocates are not alone in reaching this conclusion. Expert scientific panels which have considered all the evidence regarding nutrition and health, have delivered assessments and made recommendarion which are consistent with this position. For example

The World Cancer Research Fund states that we should
‘Eat mostly foods of plant origin
PUBLIC HEALTH GOALS
Population average consumption of non-starchy1
vegetables and of fruits to be at least 600 g (21 oz) daily2
Relatively unprocessed cereals (grains) and/or pulses
(legumes), and other foods that are a natural source of
dietary fibre, to contribute to a population average
of at least 25 g non-starch polysaccharide daily’https://www.wcrf.org/sites/default/files/english.pdf

Studies have repeatedly shown that people who eat in accordance with WHO guidelines and various national guidelines (themselves often based on the WHO guidelines) have lower mortality than those who do not

Little wonder then that Greger asks how much more evidence people need to convince them to eat more healthily.

Simply pointing to observational studies that find no association between vegetarian diets and health ignores two key points:

1. many vegetarians may not be eating healthy WFPB diets
2. people often seem to adopt vegetarian diet in response to troubling health issues or obesity. We might therefore reaonably expect them to have worse health than non-vegetarians

So grateful for dr. greger + nutritionfacts.org continued efforts to cover the evidence and spreading of misinformation. After doing internet searches and results reviews for years this is the only site where I feel I can trust i’m getting unbiased information and efforts made to look at issues from all sides.

Current chronic illness treatment by medical industry is so filled with choices of the nature “. . . do you want to deal with the symptoms of your disease or chance of reducing some of those in exchange for treatment side effects that can be as bad or worse than just living with disease symptoms”. Just as bad are the alternative/functional/integrative/naturopathic solutions that are untested and waste your time, energy and money.

Having evidence based facts on the role nutrition can play in prevention and treatment in a way that doesn’t come with negative side effects, other than having to learn to not to want the pleasure trap choices, is an empowering and valuable choice to provide people.

My husband and I began with Dr. Ornish’s books in 1993. I still use some of his recipes today. I’m not sure when I first started to read your articles, but they made so much sense to us. My husband is a open to a vegan life style. We are not yet completely vegan, but we keep trying. We have friends who have gone to a Keto diet and we are concerned for their future health. Your articles are very informative and we have learned so very much. Thank You.

Looking at Dr. Bredesen’s work at reversing Alzheimer’s, and looking at Dr. Swank with MS, I agree that they are doing amazing things, but how do we know which part of their diets is the part, which is doing amazing things.

For instance, both Swank and Bredesen are lowering saturated fats versus the SAD diet and both of them are increasing the intake of every colored fruit and vegetables, which we know changed both the nutrition and the gut microbiome, if the they are organic, and might also decrease calories (pointing to the salad study)

Dr. Fuhrman brings animal products to below 10% of the diet, but says that at 5% you can’t distinguish between vegetarian and low quantity animal products diet, but is that for Cancer? Heart Disease? Diabetes? What about the viruses and things in meat?

Seems like, YES, there is plenty evidence to get rid of processed foods and plenty of evidence to lower animal products, but after that, we need every study possible, because we have to decide whether the researchers who say all oils are bad are right and whether to limit them, like Dr. Barnard, or whether people like Dr. Bredesen are right, when he gives oils for Alzheimer’s.

I do know that it is brilliant that Dr. Bredesen reversed Alzheimer’s and regrew the brain, but I feel like getting rid of Homocysteine and Aluminum and things like mercury and mold and making sure you have enough zinc and not too much copper and get enough sleep and have your blood sugar regulated, might be enough without taking in the extra fats, and since obesity is such an issue in America, that is the type of thing, which only a study could show and having him succeed with a version of Keto is gonna make it easy to have everyone jump to Keto without understanding all of the variables and I am going to say that they really don’t understand all of the variables yet and may never.

So, yes, American’s maybe have already gone back and forth, whole milk to skim milk back to whole milk to almond and soy milk, butter to margarine, to fake butters, back to butter, sugar to alternative sweetners, to honey to truvia and stevia and Starbucks has a whole line of sweetner choices, but not date sugar yet or is it no sugars at all and what about fruit. Gluten and soy and starches and grains are all regularly on the chopping block and all gain and lose favor study by study and theory by theory and maybe it is all just gut bacteria?

I say that last part, because in a way, we are following studies and are being led astray, but WFPB has to be put in a study and we can’t even quite agree which version of WFPB to use.

There are things, which should be done, which can’t, which are frustrating.

Like getting rid of aluminum in baking products and getting rid of all those long name chemicals in food and Round Up.

But if I worked for Monsanto, I would be so angry that people want to get rid of it without proper studies.

And seeing the affects on America, I agree that we already can see the evidence in the face of obese infants and autistic children and I know it has to be getting the revelation to the people, because it is so hard to change the laws.

I like that when I bought the Food Revolution Summit package, part of it was grow organic trees in poor communities. Helping some of the farms who want to convert to convert is a worthy goal, but I heard that it takes 8 years to do it. Not sure how much of an incentive it will take to make that happen, because the farms can’t afford it.

I know that the fact that I won’t eat non-organic foods, and more and more people are making that decision has already caused the need for more organic food products.

I have lots of people who have been reached by the gluten and soy teachings.

Those were effectively communicated at a wide enough level that people got rid of them.

But for instance, limit the types of fruit and people go no fruit.
Limit starches and people go no vegetables.

Trust me, people end up going all meat.

I think I did that as a teenager, before I developed a meat allergy.

Looking up hives, maybe I was bitten by a tick?

Nope, it has to be studies, but we do a stupid studies process.

Mentally thinking about it the same way as we did for testing for drugs.

I am not afraid of being vegan, but, yes, mortality studies were designed in ways to be useless for me, but those studies brought up enough risks that I needed to know that for proper decision making.

It is going to take years to do a WFPB mortality study, but it is what needs to happen.

In the meantime, Dr. Ornish and Dr. Barnard and Dr. Bredesen and Dr. Swank and Dr. Esselstyn and Dr. Fuhrman and the rest have all done maybe “frameworks” for the longer term studies to come out of.

I don’t know if my mind is processing that properly, but it feels like there could be a “box concept” of sorts, where instead of needing full study proof, there could be a step between proof of concept and proof of concept, which is shown to reverse diseases and we don’t know yet which part of the program works, we just know that it works.

I might have crossed into my Alzheimer’s processing issues, but it seems like there is a missing paradigm shift, which could be a bridge, so that we don’t have to wait ten more years to find out whether it is Whole Food Plant Based or just getting rid of salt, which helped. (That example is because of the high salt being linked the highest to mortality in 2012 USA study.)

If I have moved into wrong thinking, forgive me.

Feels like I am “almost there” and someone with a stronger mind could think outside the box and “get it” from what I communicated.

Maybe some mathematician needs to put a concept of “weight” of the “anti-benefit” with correlation versus the burden of proof of harm of some of the things?

Or is it that we can’t be such perfectionists about the double blind process and we have to see results, and temporarily throw the doctors and scientists and press out of the bus, because they are harming us more with all the meds and over-diagnoses and inventing all of the GMO’s and things?

Everything my friends learn comes from one person basically “gossiping” what they learned on the internet.

I suspect whichever way we choose, will be corrupted by money and power and it will be like The Popcorn Effect – err in one direction, then, get frustrated and err in the other direction.

Right now, I am in err in “Fire your doctor” mode and so far, it is benefiting me, but I am still basically listening to about 50 doctors, so I didn’t fire all of them.

I start with the doctors who succeeded at reversing diseases and I put them in boxes in front of me and let them duke it out

Like Hulk versus Thor and I have researchers who are doing Alien versus Predator over in my side-ways glance and they aren’t allowed in the boxes in front of me, because if I focused on them, I would be marginalized into the wrong thing.

And I am a little nervous about the whole Infinity Wars outcomes, and I am not sure whether Big Meat or Big Eggs or Big Supplements or Big Chemical Pesticides or Big Alcohol or Big Fast Food place or Big super bug or annihilation of the gut bacteria “Avenger” team might be the main factor, but I try to just have a list of the good guys and bad guys and the question marks and go from there.

Some things might be “The Hulk” or young “Super boy” where they are often useful, but might need to not be on the battlefield, unless they have the right suit. That could be things like wheat and soy?

Neutral or Low Nutrition – which are fine and might bring some good gut bacteria, but if too many are eaten they start to add calories and take away hunger and crowd out the intake of the Super Foods. Maybe starches and iceberg lettuce are more here?

Then Loki would be the tricky often bad guy, sometimes does a good thing and Keto for epilepsy might be that and maybe the oils? Though there could be double agent oils, but they are tricky.

I am dog paddling through all of this information and sometimes genuinely hate myself for thinking it through so much.

I look at people like Dr. Barnard and he simplifies everything and I just love listening to him.

That being said, I watched Dr. McDougall tonight and he simplified everything in a different direction and I loved listening to him, too, and he would take away my MorningStar Chickn patties and my Follow Your Heart cheese (which turns out to have coconut oil, which Dr. Bredesen would have me take and it turns out that sometimes I am) and the vegan bologna sandwiches, which Dr. Barnard calls transitional foods and allows, and Dr. Bredesen doesn’t want me eating Dr. McDougall’s food, and Dr. McDougall likes having other opinions in his videos. That makes it easier. No need to argue with anyone. Or discount anyone’s opinion.

Just maybe not feel so bad eating a few slices of vegan cheese a week, but I have to figure out whether I am going to keep losing weight, and when I stop, I think I am going to test Dr. McDougall’s next, but keep Dr. Greger’s superfoods.

Dr. McDougall got me to change my bottled water to either Fiji or Volvic, because I can use silica to get the aluminum from all my cheese years out of my brain.

Lots to think about.

And, yes, I come back here and see all of my passionate thinking processes and want to not think out loud, but what happens every time I try to do that, I stop thinking entirely and I do find myself doing the math wrong. Frustrating to have to talk things through and not have even one person around me who will listen to even one sentence.

I like to review nutritional studies using the ‘5 pillars’ approach of Dr. Valter Longo. He says epidemiological studies are just one pillar, another is lab studies, a third is clinical trials, a fourth it centenarians, the last is systems analysis (compare the body’s sytems to simpler ones like a car, how do we make a car last longer, etc). In this case, wfpbd diets are strong on pillar 2, lab studies, where other diets failed. Their large scale studies have not been done, since the contents of the diet, not the name of the diet is what counts, and the wfpbd diet’s contents haven’t been tested large scale, except in a backwards way, like in the US the produce consumed in 1900 was 131 lbs/capital/annum, while in 2000 it had dropped to 11 lbs. It’s probably less by now, but maybe risen a bit from people adding produce back in? The number of centenarians (or the very old) in vegan-oriented places is statistically high if you correct for child mortality and lack of food. Well-fed plant eaters indeed seem to do quite well, especially in the lack of our greatest killers. In clinical trials wfpbd diet did the best of all diets. Esselstyn’s work with 180 patients showed 100 percent protection against heart attack, stroke, and death. His ‘control’ was the 20 people who did not continue the diet, and got 66 percent HA, STR, DEATH at the end of the 4 years. That was a test in which the actual contents of the diet were controlled to represent the wfpbd. He is even extending it now to 500 people. One dietary test showed the biggest meat eaters got worsening, while a more veggie diet either stayed the same or improved health. Like confounders in vegan and vegetarian diets, high meat diets have not per se been tested very much. The one just mentioned was only tested as a comparison against the veggie diet. So we aren’t sure about the ‘big meat’ diet either since we haven’t put people on it and tested for several years, only a few months at the most, far too short a time to measure hard endpoints.

Finally, like a car, the food you eat is like the gas you put in, and the oil. It needs to be right, and history shows we were chiefly plant eaters, from fossilized feces revealing the true fare we ate. Our digestive system evolved not in the Paleo period, which was 2 million years ago, but 23 million years ago along with the great apes. We never developed claws and teeth to consume flesh and had to wait for the brain and tools, not to mention fire, to really being consuming meat. It was a diet artifact of our evolution of mind and capabilities, not the cause of them or necessary to their existence. It probably was emergency rations all along. Now we are trying to use animal products all the time as the mainstay of our diet, while the biology has not adapted, and probably never will adapt to an omnivore or carnivore-like diet.

I haven’t really been eating starchy vegetables almost at all since last year. I can’t remember the last time I had corn or potatoes or rice. I didn’t eat bread most of the year. I feel like I understand that side of the equation, but I haven’t read the labels to get rid of the last of the oil and I haven’t tried adding in most of the starchy vegetables.

The biggest reason I am going to do it, is because my friends are afraid of gluten, soy, carbs, grains, and they are trying to go high fat and that is what Dr. Bredesen emphasized in part of his talk and I think he is also get rid of saturated fat, but I don’t like that he puts keto in his title and I need to show my friends and family if they have to be afraid of starches.

I am so excited about the Fiji Water. I feel like that will be for the next few weeks to see if getting rid of the aluminum helps with the hallucinations. Getting rid of the oils and eating the starches, will be after I test Fiji Water.

This is my contribution to my understanding of these diets. Dr. Barnard’s concept of allowing in the transition food as part of the process is still working, so it might be that I don’t even have to do extra than what I am doing now.

To be fair to Dr. Barnard, I didn’t read the labels and my cheeze has oil in it and so does the transition veggie chickn patties, and his concept helped me to succeed at giving up cheese and milk and my brain has improved some.

Next, I am going to do Fiji water for a few weeks.

Then, 4 months of Starch, no Oil, and Fiji Water which is what John says gets rid of everything.

Each step of the process, I am going to see if I am having hallucinations and if my brain processing comes back.

If the starches hurt, I will know, and if they help, I will know.

If getting rid of the small amount of coconut oil in my cheeze hurts, I will know and if it just helps me lose weight and if my brain improves without it, I will know.

When I looked up what the Coconut oil does, it said, “Coconut oil is now being used in clinical trials for improving cholesterol in patients with chronic heart disease, in fighting Alzheimer’s, and for improving blood pressure and blood sugar levels.”

Well, I take Flax seed and am eating Vegan and am not worried about blood sugar levels, so maybe you only need coconut oil if you are eating meat? And probably, if you are eating meat, and taking oil, you wouldn’t have enough calories available for starch? That is my hypothesis.

I mentioned compliance as a key to epidemiological efficacy of any process or behavior. And so we can all agree eating healthy is beneficial to longevity. But the analogy with smoking is misleading and changing the habits of the general population will take much more than a statement by the surgeon general or warning on a package.
Why? Smoking is singular act. You light up, inhale & exhale. To stop smoking you simply stop lighting up. Not so easy if you’re addicted, but straightforward NTL.
Diet is not singular. We’re talking about all sorts of foods and substances, many clearly beneficial and others patently harmful. Many substances and nutrients like salt are subject to J curves, meaning either too little or too much is harmful. Gezillion papers, studies, books and treatises on the subject, many of them advocating conflicting behaviors. We’re all aware of the diets and theories that come and go into fashion. Diet is a complex, complicated and often confusing behavior that has myriad aspects and facets, biological, microbial, medical, social and historical. Changing people’s behavior is a momentous task, one that will not be achieved merely by a government pronouncement that anything but non-poisonous plant-based whole foods are detrimental to health and associated with all sorts of diseases (not just primarily those of the lung and heart as is the case with smoking).
A better objective is to try to get people to pay attention to what they are putting into their body and the potential consequences of dietary habits. Maybe one by one, by one small group and another. If we’re successful at all in getting people to eat healthier, it’s most likely to be a slow, deliberate and incremental process, not an epiphany. C’est la vie.

As a retired industrial health care scientist, I believe that ph 3 of CCT cannot encompass the huge inter patient biological diversity….no matter how huge or well designed! Ph 3 should be eliminated and replaced with patient centric optimized dosing, starting at a single low dose gradually increased to multiple doses until response and/or toxicity…best done under the direction of a Dr or nurse practitioners. The current protocol is a costly waste of time and resources…..a major part of exorbitant Rx cost in part due to high failure rate to meet set universal end points for the selected patient panel. Ph 3 is also a source of considerable bias and data fudging ultimately leading to drug recall due to adverse effects or ineffectiveness.